It Will Take More Than Single-Payer to Make Baltimore Healthy

It Will Take More Than Single-Payer to Make Baltimore Healthy

This article appears in the Fall 2017 issue of The American Prospect magazine. Subscribe here.

“See that over there?” I pull over to the curb and Glenn Ross points to a half-acre patch of weeds and tall grass wedged between a railroad bridge and a new East Baltimore elementary school, the first to be built in the neighborhood in more than 30 years.

“You’ve got the playground there and over there’s a brownfield”—the term for the sites where factories, refineries, and other businesses closed after poisoning the land and water beneath them.

“Trains used to leave coal there,” Ross says. “Then a truck repair shop opened up. The ground there is hard and black with oil. Why would you ever build a school next to a contaminated site?”

A burly Vietnam vet and one of Baltimore’s most seasoned activists, Ross has been on the front lines of dozens of the battles facing the city’s African American community, which today makes up two-thirds of Baltimore’s 620,000 residents. Now his priority is cleaning up the brownfields and dumps that pockmark the city’s black neighborhoods, exposing the families living in them to a laundry list of toxins that have been linked to cancer and other diseases.

On the drive back to his house, we pass some of the city’s 17,000 boarded-up houses, a storefront with whitewashed windows that was once the neighborhood’s supermarket, and a building peppered with bullet holes—no particular reason why, just a calling card left by one of the city’s drug gangs.

Images like these have long made Baltimore a poster child for the urban poverty that results from institutional racism—even more so after the April 2015 death of Freddie Gray and the protests that followed. By the latest estimates, more than 28 percent of African Americans in the city live below the poverty line. The poverty rate for Baltimore households headed by women—the vast majority of whom are African American—is far higher, 41 percent.

These numbers provide as much insight into the health crisis facing African American neighborhoods as MRIs or CT scans of the individuals living within them. Maybe more. Because poverty—and the racism that gave rise to it—is the overarching reason why the life expectancy in 14 of Baltimore’s predominantly African American neighborhoods is now lower than North Korea’s.

One of those neighborhoods is the one where Glenn Ross lives, Madison/Eastend, which is 90 percent African American and where the average life expectancy is not quite 69 years. Life expectancy in the nearby Baltimore neighborhood of Medfield/Hampden/Woodberry/Remington, which is 78 percent white, is 76.5 years.

The reasons for this disparity aren’t hard to find. Compared with Medfield/Hampden/Woodberry/Remington, Ross’s neighborhood of Madison/Eastend has a homicide rate nearly 12 times higher, a cancer mortality rate 66 percent higher, and an AIDS mortality rate more than 12 times higher.

The term used to describe the factors that are responsible for such disparities is “determinants of health.” Some are the ones Ross talked about: toxins, housing, access to food, violence, and drugs. But there are others, too: education, unemployment, the number and quality of neighborhood parks, the rat population, and anything else that impacts the health of the community as a whole. And, of course, there’s the availability of health insurance and access to care. The most important of all, right? Well, no. It’s complicated.

“THERE'S A DIFFERENCE between health care, which is critically important, and the array of social, economic, and environmental determinants of health,” says Dr. Brian Smedley, co-founder and executive director of the National Collaborative for Health Equity. “In fact, the health of populations is only minimally affected by health care. Some estimates are that only 20 percent [of a population’s health] can be explained by access and the quality of care.”

The Baltimore City Health Department (BCHD) estimate is less generous. In its report “Healthy Baltimore 2020: A Blueprint for Health,” BCHD points out that although 97 percent of health-care dollars are spent on the health-care system, only 10 percent of what determines life expectancy actually happens “within the four walls of a clinic.” The other 90 percent is decided upstream, where people live, work, go to school, and spend their free time.

All of this says something about having a single-payer or a Medicare-for-all system (slogans aside, they’re really not the same thing). It’s that while either would be a vast improvement over the insurance system we have now, neither would have a profound impact on the health crisis facing African Americans.

Some who “argue that we need to expand access to health insurance tend to also believe that if we achieve universal coverage, then racial, ethnic, and socioeconomic health care and status gaps will close,” Smedley says. “That’s simply not the case.”

What’s sending black people in Baltimore to an early grave isn’t that America lacks a Canadian-style health-care system. It’s the legacy of Jim Crow.

“BLACKS SHOULD BE quarantined in isolated slums in order to reduce the incidence of civil disturbance, to prevent the spread of communicable disease into the nearby White neighborhoods, and to protect property values among the White majority.” They could be words in South Africa’s Pass Laws, but they come from the text of a 1911 Baltimore city ordinance.

The ordinance was eventually overturned, but for all the difference that made, it may as well have stayed on the books. Baltimore whites had long believed segregation was fundamental to protecting themselves from the crime, “loose morals,” and illness that were presumably endemic to African Americans. City ordinance or not, Baltimore lenders, mortgage bankers, and real-estate interests conspired in plain view to keep black families from moving into white neighborhoods.

Jim Grossfeld

On the Front Lines: Glenn Ross is campaigning to raise awareness and clean up the brownfields that abound in black Baltimore.

There was never any ambiguity about whether African Americans could get loans to buy houses in the city’s white neighborhoods, or any doubt that anyone who attempted to sell or rent to blacks would be penalized for it. In 1934, Baltimore’s homegrown segregationists gained a powerful new ally with the creation of the Federal Housing Administration (FHA), one of the crown jewels of the New Deal, which, as a matter of policy, denied mortgage insurance to black people. The feds also established the practice of redlining, literally marking off African American neighborhoods on maps and designating those who lived within them, regardless of their income, as credit risks. At the same time, the FHA was backing loans for whites—essentially underwriting their exodus from the city.

In his 2009 book, Infectious Fear: Politics, Disease, and the Health Effects of Segregation, Samuel Kelton Roberts Jr., director of Columbia University’s Institute for Research in African American Studies, provides a chilling account of how housing discrimination hastened the spread of tuberculosis in Baltimore’s African American community beginning in the early 1900s.

Roberts points out that even though African Americans made up one-fifth of Baltimore’s population, they lived on only 2 percent of its residential property and often paid rents that averaged three times higher than what whites paid for similar homes. How could they afford it? Most couldn’t. Given the poverty wages earned by most black workers, the only way many could make the rent was to take in tenants of their own. For their part, landlords had little compunction about failing to provide even rudimentary maintenance, leaving homes damp, stifling, and reeking of decay and rot. City officials provided only mediocre public services, if any. The impact on black families was devastating. In his book Not in My Neighborhood: How Bigotry Shaped a Great American City, longtime Baltimore journalist Antero Pietila points out that when Baltimore’s citywide TB rate climbed to 132 cases per 100,000 people, in one black neighborhood it had surged to 958 cases per 100,000 people. The sight of fatigued black men, women, and children suffering from chills, fever, and coughing up blood or sputum wasn’t uncommon.

While redlining didn’t create TB, it was responsible for its phenomenal spread in Baltimore’s African American community, and the illness and death that followed. A century later, redlining continues to determine the health of the city’s black neighborhoods.

Today, according to a survey by the Corporation for Enterprise Development (CFED, known today as Prosperity Now), 32 percent of black Baltimore households have no household net worth at all, and 67 percent have so meager a level of liquid savings that they could meet their basic expenses for no more than three months if they had a medical emergency or suffered a job loss.

The Institute for Policy Studies (IPS) and CFED report that if current trends continue, the average black household in the United States will need 228 years to accumulate as much wealth as their white counterparts have now. Wealth inequality, rooted in segregation, has made poverty an enduring fact of life in Baltimore. It’s the common thread to the social determinants that are robbing African Americans of their health.

WHEN CNN COVERS the health impact of the criminal justice system on the African American community, it usually begins and ends with an account of the police killing a black person. If there’s video, all the better. But police violence is a piece of a much bigger story: how the justice system undermines the health of the entire African American community.

Ralikh Hayes has been an organizer since his teens in campaigns to change the city’s criminal justice system. Ask him about the health of Black Baltimoreans and he’ll tell you that the issue he’s concerned with isn’t whether something he’s exposed to now will kill him in 20 years. It’s simply not getting shot.

“It’s a public health issue that young black people don’t think they’re going to make it to 21, 23, 25. The fact that I turned 23 is considered a milestone in the community,” he says. “People don’t think their life expectancy is that long.”

The experience of violence and degradation in black America, of course, has all too commonly come under the color of law. Police violence and abuse are a fundamental cause of the stress and trauma suffered by black people. Two-thirds of young African Americans say that they or someone they know has experienced violence or harassment at the hands of the police, according to a 2016 GenForward poll. Thirty percent of black men say they experienced it themselves. And hearing, reading, or seeing news coverage of police violence and harassment of black people can activate what psychologists call “racial trauma,” triggering memories of police harassment and other instances of racism that they and the people they know have experienced. Almost one in ten black Americans suffer from post-traumatic stress disorder, or PTSD.

“I'D GO THERE IF I had an accident, but not if I had a choice,” he says. “He” is a retired Baltimore steelworker who’s shy about being quoted by name. “There” is Baltimore’s Johns Hopkins Hospital. Together with the Mayo Clinic and the Cleveland Clinic, Hopkins is part of the trinity of top-ranked U.S. hospitals—a latter-day Lourdes to which sick people from around the world beat a path, hoping to find cures they’ll find nowhere else. But in Baltimore’s African American community, the hospital has a different reputation.

“They treat black people with disrespect,” he adds. “Whites get much better care.”

It’s a view shared by many African Americans. Many grew up having heard the story that if they played too close to Hopkins they might get snatched off the street for medical experiments. In their 2013 book Lead Wars, historians David Rosner and Gerald Markowitz revealed that as late as the 1990s researchers affiliated with Hopkins conducted a study that exposed children, most of them African American, to dangerously high amounts of lead.

One institution better able to address some health determinants than a hospital is the community health center. Today, there are 9,800 such centers (their number augmented over the past decade by the $11 billion included in the Affordable Care Act for that purpose), which provide care to 24 million low-income Americans, two-thirds of them minority. Because they’re small, located near their patients, culturally compatible, and often work with community leaders to address some of their patients’ non-clinical problems—access to healthy food, for example—they fill needs that most hospitals either don’t or can’t.

To what extent, though, does racism still affect the medical system at large? In 2015, The Journal of the American Medical Association Pediatrics reported on the findings of a study led by Dr. Monika Goyal of Children’s National Health System and Dr. Nathan Kuppermann and Sean Cleary of George Washington University. They found that “[b]lack children are less likely [than white children] to receive any pain medication for moderate pain and less likely to receive opioids for severe pain, suggesting a different threshold for treatment.”

An older study—but one that nonetheless came 36 years after the enactment of the Civil Rights Act—was published in 2000 in Social Science and Medicine. In it, Michelle van Ryn of the Mayo Clinic and Jane Burke of the University of Illinois at Chicago College of Medicine examined 842 post-angiogram encounters between physicians and their patients. They found that “lower [socioeconomic status] African Americans consulting a cardiologist are more likely than affluent Whites to be perceived as: lacking intelligence; lacking self-control; irrational; unlikely to have significant career demands; at risk for inadequate social support; unlikely to desire a physically active lifestyle; at risk for substance abuse; and likely to be noncompliant with cardiac rehabilitation.”

One change that would likely have a positive impact on the quality of health care provided to African Americans would be an increase in the number of black doctors. It’s not only a matter of African Americans feeling more comfortable having a black doctor; it’s that African American doctors may be more willing to see low-income—disproportionately minority—patients. In a 2015 New England Journal of Medicine article, Dr. David Ansell and Dr. Edwin McDonald wrote, “Black medical students are more than twice as likely as white students to express a desire to care for underserved communities of color. Our inability to recruit black men into medicine is alarming, given the urgency of racial health care disparities in the United States.”

By some measures, only about 5 percent of practicing physicians are black, and there’s little evidence that number is going to grow. In 2004, medical school enrollment for African American students was 7.4 percent, but by 2011 it dropped to 7 percent.

The reasons why have been talked over (and over) for years: Throughout K–12, schools aren’t identifying and encouraging African American students who may have an interest in medicine; schools attended by black children don’t have the same resources to teach science that predominantly white schools do; the shortage of black physicians means there are few role models; many black college graduates are unprepared to apply to medical school; and, of course, black students and their families can’t afford the staggering price of studying medicine.

For generations, historically black colleges and universities (HBCUs) like Howard University in Washington, D.C., and Meharry Medical College in Nashville trained the lion’s share of America’s black physicians. They’ve also struggled to survive financially. Now, with Donald Trump suggesting that federal support for them may be unconstitutional, HBCUs could be facing their toughest times ever.

One group working to counteract these trends is White Coats 4 Black Lives, or WC4BL, a national organization of medical students whose mission is “to eliminate racial bias in the practice of medicine and recognize racism as a threat to the health and well-being of people of color.” With 54 active chapters at medical schools across the nation, WC4BL says its primary goal, in the spirit of Black Lives Matter, is to put medicine’s racial disparities on the front burner.

Indeed, Black Lives Matter may be providing a template for dealing with all the systemic issues that threaten and thwart black lives. Earlier this year, Mustafa Santiago Ali, a former EPA senior advisor for environmental justice and community revitalization, became the senior vice president of climate, environmental justice and community revitalization at the Hip Hop Caucus. He sees a coming-together of discrete movements to improve African Americans’ lives. “The environmental justice side, the public health side, and Black Lives Matter, all these various organizations are engaged in Flint [Michigan] and understand that what’s happening there and other communities is a sign of the disinvestment that’s been happening there for decades—even longer than decades,” he says.

“There’s the Band-Aid approach, which has its relevancy, which is just focusing on the pipes and the water,” he says. “And then there’s the broader construct of making sure there’s green housing, making sure that transportation routes are beneficial to the community, utilizing job training programs, creating small anchor institutions.”

And health insurance? While it’s important, it’s no substitute for creating new clinics that provide easy access to care. Pointing to the success of community health centers that today meet the needs of more than 24 million patients in poor communities, Ali says, “We could turn brownfields into health fields by cleaning up contaminated sites and placing health-care facilities there.”

SINCE IT HAD TAKEN a couple of weeks to arrange the interview, I was thrilled to finally have him on the phone. He was one of the country’s strongest advocates for single-payer—he wished to remain anonymous—but what I wanted to talk about with him that afternoon was racial health disparities. The responses I got from him didn’t say as much about the implications of, say, food deserts or the shortage of African American doctors as they did about the current politics of much of the left. The answer to all of my questions was single-payer.

It took a lot of prodding but eventually he explained why.

“The conversation always has to be broader than [racial] disparities,” he said. “When you look at America’s will to end poverty, it was highest during the Great Depression, when the images of most poor people were white.”

Despite the fact that the health crisis facing African Americans has less to do with access to insurance than with those other social determinants, the idea that health is rationed not only by class but by race hasn’t commonly been part of the current argument for universal coverage. That’s partly the result of political calculation. Talking about black people suffering poor health more and dying sooner isn’t likely the most persuasive argument for many white voters. When Republicans sought to repeal the Affordable Care Act, one reason they failed is that Medicaid had acquired so many white recipients (by virtue of both the ACA’s raising the income eligibility threshold and the downward mobility of the white working class) that it had become impossible for Republicans to get away with deriding it as a giveaway to blacks.

But progressives should be able to walk and chew gum at the same time. They can advocate universal coverage and speak out about the health crisis that’s engulfed black America. It really isn’t that heavy a lift—unless they’ve bought the argument that talking about issues that have a unique impact on minorities is “playing identity politics.”

Winning universal access to health care, as challenging as it is worthwhile, will not in itself create health equity across the country’s racial lines. That’s the more fundamental challenge—and it’s every bit as urgent as winning universal health care. By the metric of lives cut short, it’s a good deal more urgent—and high time that progressives treat it that way.